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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ---------------------- (Complete in Triplicate) Permit N.-7;7 ".""" --------- -------- ------ -- -- -- This Permit Expires 1 Year From Date Issued Date Issued- Application is hereby made to the San Joaquin Local e!tl%Dis iet fora°per..rn!t to4con'struct'and install the work herein described. This application is made in compliance with County Ord mance No. 549 and existing Rules and" gulations: i JOB ADDRESS/LOCATION.- L_.a___ s CEN Owner's Name_------ ; CT - SUS TRA �. - Address ,... _ hon _. - -------------- -- -- EJ -------------- ----------- -- ty �. _ .. , -- - Ci ---- ;. . --- -------- ------- Phone_ = ------- Contractar's Name------ .. - Zi License ------- Installation will serve; �A6artntHouse Residence ❑ ❑ -Commercial ❑ Trailers „ Motel = _ _.. Number of living units:--------- i------ Number o of bedroms.-__-__Garbage Grinder:_____-"._._Lot Size.- - �__O--�----- -- -- -- ---- Water Supply: Public System and name---- -------- - + ----------------- _ ----------.-----------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ ; Peat Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe❑ " Fill Materia'[_..__ If es, tYPe------ - ____-_____-------------- (Plot t plan, showing size of lot, location of system in relation to,wells, buildings,.etc. must be,placed on reverse side.) NEW INSTALLATION: (No'septic tank or seepage ;pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT '[ I- SEPTIC TANK [t] Size_"- __...' s �- -----------------------Liquid Depth.--Tuu ---- Material__ Capacity--/ d--tTYpe -a�---' --."_•No. Compartments-- ; Distance.to nearest: Well � �� _ ation__.: _Pro 19�---- ' _ ''71L��" - t= �------ -- p. Line --- ---+I LEACHING LINE [ .l Na. of Lines. fdtl Length of each line. Total Length..a (I_: 1Box--- ------- : ----'D' '._Type Filter Material-_ __-. Depth Filter Material j nearest: Well_;-._� t 3 --- -- -------- --- - ------------ Distance-to ,. .... .... _ � - --- - ---- ---- --Property Line-_•-`!9; undation .__ � Q tiSEEPAGE PIT /� - .. ... � � ., Line-_01-0 ---------------- -SEEPAGE ------- - ---�[ l Depth-i. ni nneter. ------i-- ---i----Number-- ' .. . - -------------- -.Rock Size k Filled Ye N ' s� o - Water Table Depth__"'- � -� 1 Distance to nearet: Well ' _�_". Ro S' e _ [ Foundation --=------- ---------------Prop. Line- ---------- ---------------- REPAIR/ADDITION (Prev. Sanitation Permit#_"F_: _ _. i = ` = Date = = ----- ---- Septic Tank (Specify Requirements)________________________ ------ -- ;-= Disposal Field(Specify Requirements)---- -------------- ' ------- ---------- --------------------------- --- --------------------- -----=---- - r. ; (Draw existing'and'required addition on reverse side) I hereby certify that'[ have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State laws; and Rules and Regulations of the Sari Joaquin Local Health District. Home owner or licensed agents signature certifies the following: Y ; "I certify that in the performarice of-the "Work-for' which-this permit is issued, .l shall not employ any person in such manner as to become 'subject to Workman's .Compensation: laws of California.91. i Signed--------- t 'Owner - ------------- ------- ----- --Title----- ---- (I.f other than owner) 4 I 'FOR DEPARTMENT USE ONLY APPLICATIONt-CEPTED- Y �r _ ." --- ----- - DIVISION OF LAND NUMBER - ' --- DATE .. � TE lADDITIONAL COMMENTS.------- ----- - --------------------- ------------------------ dca ___'" " -. ------------------- ----------- ------------------------------------------------- ------ ------------------- ----------- ------------ -- ---------- ---- ------------------ --------- --------------------------------- ------ 1 .� --- --¢ '`' Final Inspection by:.:--- - --- --...__:" ,�_-� .... .-�---. ----------------------------- ----- ---- -------- ------------� -- - - -- _��_�-r----------- -------- --- w Date - . -_ -------- --=--------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M